<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750054
Report Date: 07/14/2021
Date Signed: 07/14/2021 12:40:13 PM

Document Has Been Signed on 07/14/2021 12:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:EVO TAEKWONDO ACADEMYFACILITY NUMBER:
197750054
ADMINISTRATOR:THORNTON, KYLEFACILITY TYPE:
840
ADDRESS:43437 GADSDENTELEPHONE:
(661) 609-1568
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 60TOTAL ENROLLED CHILDREN: 0CENSUS: 39DATE:
07/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Kyle ThorntonTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On July 14, 2021 ay 10:31AM, Licensing Program Analyst (LPA) Brigitte Tsutaoka conducted an unannounced Case Management - Incident inspection regarding a child injury self-disclosed by Director, Kyle Thornton. LPA met with Director and disclosed the purpose of inspection. Upon entry, LPA counted 7 staff, Director and 39 school-aged children.

During inspection, LPA interviewed Children and Staff. Child 1 was engaging in a game of dodgeball with the other children, was running away from a ball being thrown at him, and tripped over a "rainbow ball" that landed on the ground causing him to twist his ankle. The children play dodgeball as a method of agility training. Staff 1 and Child 2 assisted Child 1 immediately and ice was administered to the injured ankle. Child 1 sat out the next activity while icing his ankle and Parent 1 came approximately an hour after the injury to check on Child 1. Parent 1 decided to take home Child 1 to rest his ankle. By the time Parent 1 came to pick up Child 1, he was able to walk on his ankle, but was taken home as a precaution to make sure his ankle did not sustain a serious injury.

Based on evidence obtained and interviews conducted, the injury sustained was an accident and was not a result of negligence or lack of supervision by the center. No citations will be issued today according to Title 22 Regulations. Consultation provided during the inspection. Exit Interview conducted and a copy of report was read and provided to Director, Kyle Thornton.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Brigitte Tsutaoka
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1